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Elife. 2017 Oct 5;6. pii: e29365. doi: 10.7554/eLife.29365.

Effects of water, sanitation, handwashing, and nutritional interventions on telomere length among children in a cluster-randomized controlled trial in rural Bangladesh.

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School of Public Health, University of California, Berkeley, Berkeley, United States.
Department of Biochemistry and Biophysics, University of California, San Francisco, San Francisco, United States.
Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh.
Department of Nutrition, University of California, Davis, Davis, United States.
Sylvester Comprehensive Cancer Center, Department of Psychiatry and Behavioral Sciences, Miller School of Medicine, University of Miami, Miami, United States.
Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, United States.


Background: Shorter childhood telomere length (TL) and more rapid TL attrition are widely regarded as manifestations of stress. However, the potential effects of health interventions on child TL are unknown. We hypothesized that a water, sanitation, handwashing (WSH), and nutritional intervention would slow TL attrition during the first two years of life. Methods: In a trial in rural Bangladesh (, NCT01590095), we randomized geographical clusters of pregnant women into individual water treatment, sanitation, handwashing, nutrition, combined WSH, combined nutrition plus WSH (N + WSH), or control arms. We conducted a substudy enrolling children from the control arm and the N + WSH intervention arm. Participants and outcome assessors were not masked; analyses were masked. Relative TL was measured at 1 and 2 years after intervention, and the change in relative TL was reported. Analysis was intention-to-treat. Findings: Between May 2012 and July 2013, in the overall trial, we randomized 720 geographical clusters of 5551 pregnant women to a control or an intervention arm. In this substudy, after 1 year of intervention, we assessed a total of 662 children (341 intervention and 321 control) and 713 children after 2 years of intervention (383 intervention and 330 control). Children in the intervention arm had significantly shorter relative TL compared with controls after 1 year of intervention (difference -163 base pairs (bp), p=0.001). Between years 1 and 2, TL increased in the intervention arm (+76 bp) and decreased in the controls (-23 bp) (p=0.050). After 2 years, there was no difference between the arms (p=0.305). Interpretation: Our unexpected finding of increased telomere attrition during the first year of life in the intervention group suggests that rapid telomere attrition during this critical period could reflect the improved growth in the intervention group, rather than accumulated stress. Funding: The Bill and Melinda Gates Foundation.


child intervention; epidemiology; global health; human; low-income; nutrition; randomized controlled trial; telomere length; water, sanitation, hygiene

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